The HCPs also added that, with the use of the DITE app, Deaf patients can more readily have access to professional third-party interpretation services, rather than having to rely on casual interpretation by their family members or friends. Not only does this prevent information from being lost or modified (should family/friend selectively translate), it also creates a more conducive environment for patients to open-up: “The patient is speaking to someone who is totally unknown, so they will be able to open whatever that is withhold, because in real life, they come with their family, sometimes I wonder how much of what I am being said is being passed on, but now it is a total stranger, so they might also be able to totally open up” (HCP5, F).
Subtheme 3: Streamlining logistics and efficiency
Another point raised was that the usage of the DITE app could greatly facilitate logistical arrangements given the fact that it allows pre-bookings with the JBIMs: “I like that (…) this is pre-booked, because in a sense that sometimes when I am in the hospital and I run into problems with translating for [immigrant patients who cannot communicate with English or Malay], I actually have to wait for the physical interpreter to be free, and they can only come at X time for example, and I have to coordinate with the patient’s family who can only come at X time. So, I can end up easily a delay of surgery of 1 to 2 days just trying to coordinate everyone to sit down together to get the damn consent. So, I think with the app, the fact that its pre-booked, I can arrange the time. I'm looking forward to it shortening the logistics as well as the effort required just to arrange a meeting” (HCP2, F).
Theme 2: Limitations of the DITE app
Subtheme 1: Limited non-verbal communication and interaction
On the other hand, the HCPs also noticed some limitations to the trialled version of the DITE app. Firstly, the DITE app did not allow all three stakeholders (the HCP, JBIM, and BNUs) to see each other simultaneously, as what would happen should the interpretation be conducted in-person. During the simulation, the patient’s device was positioned such that the JBIM and the patient would see each other through the screens of their devices, whereas the HCP and JBIM could not see each other. In addition, the patients will be focused on the screen of their device, rather than on the HCP, hence there will be a total lack of eye-contact between both the HCP-JBIM and HCP-BNU. HCPs felt that this limited their ability to effectively integrate non-verbal cues and physical demonstrations during their speech, thereby serving as a barrier to communication. For example, HCP2 explained: “I wanted to demonstrate to the patient what (exercises) I wanted him or her to do and then to feedback to me what were the sensation the patient experienced as they were performing the examination. So, because the camera was initially only focused on the patient, the translator couldn’t see what I was doing to explain it to the patient (...) The second thing was also that there were sometimes, when I wanted to get the patient’s attention but again, they were so focused on the screen, so I had to actively reach out to the deaf patient, touch them, get their attention, ‘look at me’, and then explain, and then turn the camera to get them to explain…” (HCP2, F). It was also raised by the HCPs that the lack of eye-contact not only inhibits the HCPs from expressing themselves through non-verbal cues, but also deters them from picking-up the non-verbal cues from Deaf patients, which they think is equally important in the HCP-patient communication.
Limiting conditions
Limiting conditions are understood as the degree to which the HCPs believe that their work environment would deter the use of the DITE app during their consultations with Deaf patients.
Theme 1: Potential Challenges in Real-World Implementation
Subtheme 1: Environmental distractions and resource limitations
During the FGD, the need for a conducive environment to use the DITE app was brought to light by a few of the participants. When asked whether the HCPs would use the app during consultations, one said “Depends on the scenario, if it’s in ED, labour room, with all sorts of distraction, I don't think it will be very conducive and then I will be like fine, I’ll use pen and paper instead.” (HCP6, F). Additionally, some HCPs indicated that there was a lack of necessary resources at their workplace to conduct a successful consultation utilising the DITE app. They suggested necessities such as a strong WIFI connection and even tripods would be difficult to access.
Subtheme 2: User familiarity and technical challenges
Many of the HCPs noted that patients faced difficulties during the consultation as they were unfamiliar with the use of the technology. According to one HCP, the interpreter hadn’t downloaded the correct link, so they were unable to proceed. Another HCP stated that at one point the Deaf patient and the interpreter couldn’t see each other as one of them had not clicked on something and at another point, both the Deaf patient as well as the interpreter couldn’t hear the HCP. One added that both his patients found it difficult to attach a phone to the tripod located on the table as well.
Subtheme 3: Appointment scheduling complexity
When using the DITE app, Deaf patients are allowed to pre-book their timeslot with an interpreter. However, HCPs noted that in the real-world, at clinics, with long queues and unknown waiting times, this becomes a hurdle as the patient is unaware of what time their appointment will be.
Social influence
Social influence is understood as the extent to which other medical professionals’ beliefs and opinions of the DITE app influence a HCP’s perception.
Theme 1: Data Privacy and Patient Confidentiality
There were shared concerns for data privacy and patient confidentiality with the use of a third-party app during medical consultations as HCPs were worried that conversations with patients would be recorded. Queries such as what would be done with the recordings, who has access to it, how they would be stored, how long they would be stored for, and whether they would be used for any other purposes, arose as the possibility of a leak is a real threat to patient confidentiality. Further concerns were highlighted regarding obtaining patient consent, as patients had to be informed of what and how exactly they were consenting to use the recordings. On the other hand, the benefit of consultations being recorded was also acknowledged in the case that a medicolegal complication was to arise.
Theme 2: Medicolegal Acceptance of DITE App Translations
HCPs expressed concern as to whether using the DITE app to translate is medicolegally accepted. As an element of obtaining patient consent, patients are required to disclose who explained what they were consenting to. This would generally have been done by the hospital’s official translator. However, when translations are done via the app there isn’t an ‘official hospital translator’ as such, which is an issue. To overcome this obstacle, the HCPs suggested exploring the possibility of using the sign language interpreter’s name on the consent form as a legal translator to fulfil this requirement and suggested looking over whether it is applicable to surgical procedures as well. This is of importance as should a communication breakdown occur with a Deaf patient and they decide to take legal action, it goes back to all the records and documentation, “… which record do you take on board, do you take on board the recording of the consulting between the SLI and the patient? Do you take on board the transcript of the doctor having recorded his or her perception of the conversation. Maybe, again once you have all the legal bits ironed out, then I’d feel more comfortable because my signature is on the form at the end of the day.”(HCP2, F)
Behavioural Intention
Theme 1: Usage and promotion of DITE app
When asked about their willingness to use and advocate for the use of the DITE app in future consultations with Deaf patients, all HCPs answered affirmatively, with the condition that the major concerns mentioned in above are resolved.
Areas for improvement
Theme 1: Drawing functionality and spelling assistance
The use of the DITE app enabled the HCPs to take a more detailed history in many ways. However, the lack of a function to draw out diagrams on the app directly, acted as a barrier to conveying some of the explanations across smoothly. On one occasion, the HCP used a pen and paper to illustrate an explanation and then first showed it to the translator on screen and then again to the patient. Another such instance was when the patient proceeded to spell out the name of a medication and the interpreter couldn’t quite catch the spelling and had difficulty interpreting it even after the patient had spelt it multiple times. As seen from the two previous examples, a drawing feature built into the app itself would be a great addition for all three parties, especially during surgical procedures as otherwise the practitioner would have to draw out the whole anatomy and also explain in further detail, which would be quite tedious.
Theme 2: Improving visibility and interaction
HCPs highlighted that the camera and screen were only facing the patient, which prevented HCPs from seeing the interpreter throughout the consultation,“…sometimes I feel both of them are talking to each other then I’m talking to the interpreter instead of the patient. I'm looking at the patient but the patient is not looking at me.” (HCP4, F). Participants expressed that being able to see the interpreter’s face in addition to the patient’s face, in a similar manner to that of the telecommunication consultations, would be beneficial as they would be able to gauge whether they were speaking too fast or slow, or even needed to stop talking if there were any issues/ miscommunication. Furthermore, they added that the ability for all three parties to make eye contact would enable the HCP to build a better rapport with the patient.
SLIs
Demographic details
The majority of participants were males (67%), and all were freelance interpreters. The majority used android phones (67%) and of the six, only one had received training for the medical setting. Of the two who had experience interpreting in the medical setting, they interpreted 0–5 times in the past one year. Further details are provided in Table 3.
Table 3
Characteristics of JBIM participants (n = 6)
Characteristics | n (%) |
Age | |
31–40 | 3 (50.0) |
51–60 | 2 (33.3) |
61–70 | 1 (16.7) |
Number of years as an interpreter | |
< 1 year | 1 (16.7) |
2–5 years | 1 (16.7) |
6–10 years | 1 (16.7) |
> 10 years | 3 (50.0) |
Ability to reverse translate | |
Maybe | 4 (66.7) |
Yes | 2 (33.3) |
Experience interpreting in medical setting | |
Yes | 2 (33.3 |
No | 4 (66.7) |
Highest qualification | |
Diploma | 1 (16.7) |
Undergraduate | 2 (33.3) |
Postgraduate | 3 (50.0) |
An overview of the themes and subthemes are presented in Fig. 3.
Performance Expectancy
Theme 1: Strengths of DITE app
Subtheme 1: Improving interpreter’s service & performance
With the use of the DITE app, participants believe that their productivity as a JBIM increased. As they are able to provide their services without being physically present at the healthcare facility, participants were able to accept more bookings with the extra time. This is illustrated in the following quote: “... It improved (my) productivity in the sense that I could probably help more Deaf (people) (…) with this (DITE app), I could have multiple bookings back-to-back throughout the day, or you know, on demand...” (JBIM 2, M) JBIMs felt the DITE app allowed them to provide their service to BNUs from different states across Malaysia. This is particularly useful as there are limited numbers of JBIMs. Additionally, participants unanimously agreed that the use of the DITE app reduced consultation time. The ability to provide interpretation services remotely also served an advantage of time as they need not spend time travelling: “…(By) using the app, I don’t have to travel over there (to be physically present at the consultation), and this can save up a lot a lot of time.” (JBIM 3, M)
One of the participants also shared their personal experience of a medical emergency, where the DITE app’s advantage of virtual interpretation would have been lifesaving: “… few months back there was an accident which happened to a Deaf … and it was during peak hour, about 5PM or 6PM. He called me and he said: “Can you come because I need an interpreter?”. And from my home to (the) hospital, it takes minimum one hour during peak hours, and doctors cannot wait for that one hour. And if with this app… I can immediately (provide the interpreting service) to the doctors and to the Deaf. But because we don’t have this thing (DITE app), I can’t go (to the patient physically). Even if I went, the doctor cannot wait for me, so it (the physical distance and the lack of a suitable video conferencing tool such as the app) become such a big problem. In the emergency situation, this app would really come in handy. And even during pandemic, we had to go to, I’m talking about myself, I go to the hospital to interpret for the Deaf. I have to be physically there, and now, with this app, I would say it is really fantastic.” (JBIM4, M)
The interface face of the DITE app which allows BNUs to view all available JBIMs and select their preferred JBIM was noted as a helpful and user-friendly feature, with a JBMI saying “…it (DITE app) is good because for the Deaf, they can see all the interpreters’ name and contact. So, this is a plus point to this app. They can straight away pull up and select (their preferred interpreter) or put up their demand and the interpreters who see it can immediately react to it. As compared to using Zoom or other apps where you don’t know who the interpreters are. You cannot choose.” (JBIM1, F)
Subtheme 2: Video and audio quality
Participants revealed that the quality of the DITE app’s audio and video was satisfactory to facilitate their interpretation. This includes appropriate size and quality of video displayed on the app and good audio clarity. This is illustrated in the following comment: “For me, the app is fantastic… Number one, I can see (BNUs) clearly as the Deaf is actually being highlighted as my main point, because if the Deaf is very small, I cannot see whatever that was communicated to me. That’s number one, (where the Deaf) is highlighted big enough. Number two is the voice (audio quality). The quality of the voice (audio) is also quite good, because whatever the doctor says, if I cannot hear it, I cannot interpret. But in this app, it is quite clear, so for me it doesn’t have any big problem.” (JBIM4, M)
Theme 2: Limitations of DITE app
Participants disclosed that multiple limitations hindered their interpretation process. This included limited view of the JBIMs, especially when they needed to sign using body parts that were beyond the camera’s field of view: “…I’m very satisfied with it (DITE app). But of course, if I can go physically, it will be much better, because I can see the whole thing (body gesture of the doctor and the patient), and I can show them the whole thing (entire body gesture), (while using the app) can only show them part of it. Before (when interpreting) medical terms, sometimes you (JBIMs) would need to sign up to your neck or your leg, or (perform some actions) so it will be easier for them to understand. This limitation happens because we are using phones, which screens are quite small.” (JBIM3, M)
The limited field of view also interfered with the interpretation process during physical examinations. When the HCPs performed physical examinations on BNUs, the JBIMs were unable to interpret accordingly as the physical examination was not captured by the camera, with one noting “…we can’t see the doctor... (when) the doctors say: “OK, I want to check your hand” … we will just tell the Deaf: “Stretch out your hand”. But (when using DITE), we don’t know where the doctor is pressing (on) the hand (of the Deaf), or which part of it, we will just interpret whatever the doctor told us, or (we will just tell the Deaf): “Now I am pressing on this part, how do you feel?”. When the Deaf stretch out their hands to the doctor, their eye contact is not on the screen (focusing on the interpreters), they are looking at their hands… So, in this way, there is a little bit of slowing down (of the interpretation because) we have to ask: Okay, please look at me first. How is it? When pressing on this part (the part which the doctor is pressing on) how do you feel? Then only would they (BNUs) express to you. (JBIMs).” (JBIM1, F)
Participants also questioned the feasibility of using the DITE app in a real-world setting, particularly when the environment is less conducive: “…just now when I try to interpret, there was some (construction) work going on. So, there was a (background noise) ... If you are looking at an actual environment, maybe the surrounding is very noisy so you cannot hear.” (JBIM 3, M) Finally, participants noted that the lack of notification features such as ringtones when a booking was received and this could potentially lead to unnoticed calls that are missed, as noted by one JBIM: “…now we are under testing, so I was very alert with what I have. I will check (my phone for notifications) every time, but normally I don’t check my phone, only when there is some ringing. So, when there is no ringing, I won’t know if there is an incoming call. Even in an emergency, I won’t know.” (JBIM3, M)
Effort Expectancy
Theme 1: Navigating DITE app
Participants agreed that navigating and mastering the DITE app was effortless and easy. However, some participants did face minor troubles as they were unsure how to properly use the DITE app. For instance, one participant did not know that they had to turn on the ‘I’m available’ option in the app, leading to their status showing as they were unavailable.
Theme 2: DITE app interface
Participants also had issues with the DITE app being unable to update their booking status automatically after accepting a booking. They received error messages that would only be resolved when participants manually refreshed the app. One participant suggested "...if there is an arrow or something to show you to pull down to refresh, that would be helpful.” (JBIM 6, M)
Social influence
Theme 1: Encouragement to use DITE app from relevant stakeholders
Participants were asked if they believe that relevant stakeholders such as other JBIMs, Deaf associations, and HCPs would encourage the use of DITE app. One of the participants was confident that there would be encouragement from these stakeholders, citing the improvement in accessibility to interpreter services as the motivator, “I think yes, definitely, because like during the pandemic time, and even prior to pandemic, when we had a fear about one of our best friends being admitted to the hospital, you know it was so difficult they needed to get interpreters to go there and all, and a lot of us were working because we have our full-time jobs, so it's very difficult for us to take time off to go there. But with that app, it is so much easier. They (BNUs) don't have to tell us to go there. Just use the app and we (JBIMs) are available to interpret from wherever we are. So, I think it's something that a lot of people, our peers, and even the Deaf would be very keen to use.” (JBIM 2, M)
Facilitating conditions
Theme 1: Previous experience with telecommunication
All participants had experience using other teleconferencing apps for video calls. During the COVID-19 pandemic where social distancing measures were in place, the use of teleconferencing apps surged, and this experience was deemed useful in easing the process of navigating the DITE app.
Theme 2: Environment and supportive devices
A quiet and appropriate background was deemed necessary by the participants to fully optimize the use of the DITE app: “I think the area that I was placed at was quite good, because first of all, it was quiet and then second thing which was very important for me was that it was a clear empty background behind me.” (JBIM6, M) Resources should also be available to support the use of the DITE app. This includes the availability of Internet access and additional devices such as headphones, especially when the surroundings are noisy.
Limiting conditions
Theme 1: Lack of cultural competency among HCP
Participants found that there was a need to improve the cultural competency of HCPs, particularly when communicating with a Deaf-sign user in the presence of an interpreter. During the simulated consultations, participants noted that the HCPs were either speaking too quickly or too slowly. This made it difficult for the participants to interpret to the patient, as captured in the following comments:
“When the voice was tested just now, the doctor was speaking too fast. It's very difficult to catch up. (I had to ask the doctor), ‘What was it again, sorry’.” (JBIM 5, F)
“I think (speaking) too slow also makes it very difficult because sometimes I want to listen to the whole sentence to know what else (the doctor) wants to say. I want to hear everything, before I sign, and the Deaf are waiting (for me to interpret).” (JBIM 3, M)
Theme 2: DITE app not available on iPhone operating system (iOS)
As the DITE app was not available on the iPhone operating system, participants stated that this was one of the major limiting conditions as they struggled to find and navigate an Android phone: “I feel that because (the app is not available on) iOS (iPhone operating system) phones, so for me, I did face some problems because I need to look for another Android phone… Besides, I am not so used to Android phones, this was the first time I have used an Android phone, so it also posed an issue to me.” (JBIM1, F)
Theme 3: Difficulty in signing medical terminologies
Participants also revealed that they were challenged with medical terminologies that were difficult to sign as “I find the medical terminologies difficult to spell. For example, in the (simulation) just now, we had to ask the doctors how to spell the names of the medications. We were not familiar with the (medical) terminologies” (JBIM5, F)
Behavioural intention
Theme 1: Promotion and use of the DITE app
When asked if they would use the DITE app frequently when it is available, participants unanimously agreed that they would. However, one participant mentioned that they would not use the app all the time, depending on the role they are playing in the consultation, “For me, it’s 50–50. It is all dependent on my role. If I know them personally, I prefer to go to them... because apart from interpreting, I’m also their friend, I also want to visit them. So, I can do two things at once. But for someone I do not really know, I prefer using this app. So, it depends on what the role that I’m playing is.” (JBIM4, M) Participants unanimously agreed that they would encourage other stakeholders such as doctors to use the DITE app.
Areas for improvement
Theme 1: User guide
With the aforementioned challenges in using the DITE app, the moderator suggested to establish a user guide, and this was positively accepted by participants. The user guide would clearly delineate practical approaches to maximize the benefits of the DITE app. This includes features that needed to be switched on, positioning of the device, and instructions on how to use the DITE app during physical examinations.
Theme 2: Communication and setting expectations
Participants suggested that DITE app is designed so that the HCP, JBIM, and BNU can be seen on the screen to allow for three-way communication. However, this should not compromise the view of the BNUs. Hence, there needs to be a feature that allows JBIM to pin the BNU on their screen: “I would prefer it if there were a three-way (communication), because, (during the simulation), it was just two ways (BNUs and JBIMs), but if we have three-way and pinning are there, then yeah it will be a lot better.” (JBIM2, M)
Additionally, participants also found that there was a need to communicate with BNUs and HCPs before the consultation. It was noted that communicating with HCPs would be a method to overcome the lack of Deaf culture awareness among HCPs. This provides an opportunity for JBIMs to inform HCPs that they are not medically trained and to avoid medical jargons. Privacy and confidentiality of information could also be reassured to HCPs during this process, with one noting: “…if I (am interpreting in a) medical setting, I would want to meet up with the doctor first. Why? Because I'm going to tell them that I am representing the Deaf, so that they know that certain P&C (privacy & confidentiality) thing I am allowed to do. Number 2, they also know that I am not a medical trainee. They have to cut short some of the some of the medical terms by using very laymen language. Otherwise, whatever word you say to me, I have to spell it to the Deaf. If I don't understand, the Deaf definitely don’t understand. It’s just a word, but what is that word? So, that is the preliminary meeting with the doctor which is compulsory. And from there, if you want to talk about the speed and if the app allows us to have just a two-minute talk to the doctor, then it will be fantastic.” (JBIM4, M)
Communicating with BNUs before the consultation was also necessary to understand the literacy level of the patient and their fluency in BIM: “we have to know who our clients are, and their respective background in sign language before the consultation. Sometimes, for Deaf people, their level of (expertise) in sign language differs. So I think before the call, interpreters can first meet up with the client, so we can check with the client on their level of comprehension in sign language, and whether they can keep up with the interpreters” (JBIM5, F)
Theme 3: Notification for calls and emergency bookings
With regards to the lack of notification when participants received bookings, participants suggested the DITE app should include ringtones as a notification and to have a special ringtone for emergency bookings. Participants also mentioned a need for pop-up notifications for emergency bookings to make it more eye-catching, with one saying “…those in emergency cases, those (who are calling) on demand, (the ringtone should be) something that really catches our attention, telling us that: “Hey, the app requires our attention now”. Yeah, it could be a siren or something. Something that is not a common ringtone that people would be using. Yeah, because if it's a normal ringtone we would... like... just ignore it. But if it is something that alerts us, that the app requires our attention, yeah, (we would attend to the app).” (JBIM2, M)
Participants also hope to see the incorporation of emergency booking status in the DITE app. Whenever BNUs request for an emergency booking, JBIMs hope to receive an update on whether the request has been fulfilled, especially when they are unable to attend to them: “I think, especially when they apply for the ‘on demand’ (emergency booking), (I want to know) whether another interpreter accepts it. (If) I'm not able to pick up, at the back of my mind, “Oh my gosh, did somebody pick it up or not, or is that Deaf person left hanging there without anybody assisting,” because I have no idea whether it’s picked up or not.” (JBIM2, M)
Theme 4: DITE app logo and icons
Participants suggested that the logo of the DITE app should include components that represent Deaf and health. This would inform users that the app was meant for the Deaf and healthcare consultations, saying “The sign (logo) will be related to Deaf and medical, so at least when they look at it, they know that this is helpful for the Deaf in medical consultations.” (JBIM1, F) One of the participants also revealed that some BNUs may navigate the app through graphic representations rather than words. Hence, the app should incorporate graphic icons to improve its user-friendliness as “…we know that Deaf is the eye person (uses their eyes to navigate). So instead of putting words in the icon there, it would be better (if) you could change it to an emoji.” (JBIM4, M)
Theme 5: Additional features
Participants identified multiple features that could be included in the DITE app to improve its effectiveness and user experience. Firstly, a suggestion was made to include the data of interpreters available in Malaysia into the DITE app. This allows BNUs to easily search for their preferred interpreters and make bookings for their healthcare consultation. Participants found that there were safety concerns regarding the identity of the users. Hence, a suggestion to have identity verification in the DITE app was made. This would ensure that bookings were made by those who truly needed it: “…in order to use the app, them (users) needing to at least upload their profile and a picture of themselves before they can actually start using it, so at least when you (JBIMs) accept it, you can identify the person. They are legit, not something like (a robot or spam).” (JBIM6, M)
Additionally, participants also noted the need for close captioning during the healthcare consultations, especially for medical terms. This is highlighted in the following comment: “If we can see what the doctor said on the screen, (that would be good). Because for some medical terms, we may not be very familiar. If it can appear at the bottom of the screen, we don't have to ask the doctor what he was trying to say or how to spell the word. It may not be accurate, but at least, we already know, more or less, what it is.” (JBIM4, M) There was also a suggestion to record the healthcare consultation to cross-check whether the interpretation was accurate, as “For me, (the recording is) not for the doctor, (it is) only for the Deaf, to see whether what they are signing is correct or incorrect, (or) if the voice-over is correct or incorrect. We need the recording (of the consultation) for the Deaf.” (JBIM5, F)
To improve the convenience and user experience of the DITE app, the moderator explored the feasibility and benefits of syncing the bookings in the DITE app to the participants’ personal calendars such as Google Calendar. Participants agreed that this would be a good feature to have. Finally, participants believed that the potential of the DITE app could be expanded beyond the limits of medical consultations: “In terms of using it in a medical setting, I think it can be expanded from medical settings because I think the ‘on demand’ and the ‘booking’ features, are not just limited to medical settings.” (JBIM6, M)